The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse would assess the client during dialysis for which associated manifestations?

Hypertension, tachycardia, and fever.

Hypotension, bradycardia, and hypothermia.

Restlessness, irritability, and generalized weakness.

Headache, deteriorating level of consciousness, and twitching.

Answer and Explanation

The Correct Answer is D

Choice A reason: Hypertension and tachycardia may occur in dialysis but aren’t specific to disequilibrium syndrome, which causes neurological symptoms. Headache and twitching are key, making this incorrect, as it’s less precise than the nurse’s expected manifestations of disequilibrium syndrome.

Choice B reason: Hypotension may occur in dialysis, but bradycardia and hypothermia aren’t typical of disequilibrium syndrome, which affects the brain. Deteriorating consciousness is correct, making this incorrect, as it doesn’t align with the nurse’s assessment for this complication.

Choice C reason: Restlessness and weakness are vague and less specific than headache and twitching, which indicate cerebral edema in disequilibrium syndrome. This is incorrect, as it’s not the primary manifestation the nurse would assess in the dialysis client.

Choice D reason: Headache, deteriorating consciousness, and twitching indicate disequilibrium syndrome due to rapid osmotic shifts during hemodialysis. This aligns with neurological assessment, making it the correct set of manifestations the nurse would monitor in the client at risk.

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Correct Answer is ["D","E","F"]

Explanation

Choice A reason: Diarrhea is less common in acute pancreatitis, which typically causes nausea and vomiting. Flank discoloration is a specific sign, making this incorrect, as it’s not a primary finding the nurse would expect in the assessment of acute pancreatitis.

Choice B reason: Black tarry stools indicate upper GI bleeding, not pancreatitis, which causes pain and guarding. Left quadrant pain is typical, making this incorrect, as it’s unrelated to the nurse’s expected findings in a client with suspected acute pancreatitis.

Choice C reason: Hyperactive bowel sounds suggest obstruction, not pancreatitis, which often causes hypoactive sounds due to inflammation. Abdominal tenderness is correct, making this incorrect, as it doesn’t align with the nurse’s anticipated findings in acute pancreatitis assessment.

Choice D reason: Gray, including its reasoning, and a gray-blue flank (Cullen’s or Grey Turner’s sign) indicates severe pancreatitis with hemorrhage. This aligns with severe pancreatitis assessment, making it a correct finding the nurse would expect in suspected acute pancreatitis.

Choice E reason: Abdominal guarding and tenderness result from pancreatic inflammation, common in acute pancreatitis. This aligns with abdominal assessment findings, making it a correct manifestation the nurse would identify in a client with suspected acute pancreatitis.

Choice F reason: Left upper quadrant pain radiating to the back is classic in acute pancreatitis due to pancreatic inflammation. This aligns with clinical assessment, making it a correct finding the nurse would expect in a client with suspected acute pancreatitis.

A. Clamp the T-tube. B. Irrigate the T-tube. C. Notify the surgeon. D. Document the findings.

Correct Answer is C

Explanation

Choice A reason: Clamping the T-tube risks bile backup and infection, especially with 750 mL drainage. Notifying the surgeon addresses potential complications, making this incorrect, as it’s unsafe compared to the nurse’s priority of reporting excessive T-tube output.

Choice B reason: Irrigating the T-tube without medical orders risks dislodging it or causing infection. Notifying the surgeon is appropriate for 750 mL drainage, making this incorrect, as it’s risky compared to the nurse’s action to seek medical evaluation.

Choice C reason: Notifying the surgeon is most appropriate, as 750 mL of T-tube drainage may indicate a complication like bile leak or obstruction. This aligns with post-surgical care protocols, making it the correct intervention for the nurse to address excessive drainage.

Choice D reason: Documenting is necessary but doesn’t address the potential complication of 750 mL drainage. Notifying the surgeon is urgent, making this incorrect, as it delays the nurse’s priority of reporting a significant post-surgical T-tube output to the surgeon.

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The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse would assess the client during dialysis for which associated manifestations?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? (Select all that apply)

Correct Answer is ["D","E","F"]

Explanation

The nurse notes that a client’s T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate?

Correct Answer is C

Explanation

You are working on a busy unit and need to delegate tasks to the LPN and M

A client is being treated for diabetes insipidus (DI) with synthetic vasopressin (desmopressin). What is the priority health teaching that the nurse provides regarding drug therapy?

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? (Select all that apply)

A nurse teaches a client with a new permanent pacemaker. Which instructions would the nurse include in this client’s teaching? (Select all that apply)

A client with chronic kidney disease being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious, and the nurse suspects air embolism. What are the priority nursing actions? (Select all that apply)